617

Kangaroo mother care (KMC) is a method of care of preterm or low

birth weight (LBW) neonates by placing them in skin-to-skin (STS)

contact with mother or other caregiver in order to ensure their 1-4optimum growth and development. Initially devised as an

alternative to conventional technology-based care, KMC is now

considered as the standard of care for LBW neonates in all settings.

The Cochrane review on benefits of KMC demonstrated: • Improved exclusive breast feeding at discharge or 40 to 41 weeks’

postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25 and at 1 to 3 months’

follow-up (RR 1.20, 95% CI 1.01 to 1.43)• Reduction in the risk of mortality (RR 0.60; 95% CI 0.39-0.92)• Reduction in nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to

0.54 )• Reduction in hypothermia• Reduction in length of hospital stay (mean difference 2.4 days, 95%

CI 0.7 to 4.1)• Increase in:

Weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9)Length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38)Head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22)

1. Kangaroo position• The kangaroo position consists of skin-to-skin contact

(SSC) between the mother and the neonate in a vertical

position, between the mother’s breasts and under her

clothes• The provider must keep herself in a semi- reclining

position to avoid the gastric reflux in the neonates• The kangaroo position is maintained until the neonate no

longer tolerates it- as indicated by sweating or refusing to

stay in KMC position

5Benefits of KMC: What is the evidence?

6-8Components of KMC

Kangaroo Mother Care54

• When continuous care is not possible, the kangaroo

position can be used intermittently, providing the proven

emotional and breastfeeding promotion benefits• The kangaroo position must be offered for as long as

possible (but at least 1-2 hr/sitting), provided the neonate

tolerates it well.

2. Kangaroo nutrition• Kangaroo nutrition is the delivery of nutrition to

“kangarooed” neonates as soon as oral feeding is possible. • Goal is to provide exclusive or nearly exclusive

breastfeeding with fortification, if needed.

3. Kangaroo discharge and follow up • Early home discharge in the kangaroo position from the

neonatal unit is one of the key components of KMC. • Mothers at home require adequate support and follow-up;

hence a follow-up program and access to emergency

services must be ensured.

1. No specialized care for LBW neonatesLBW neonates born at home or at first level health facility with

no specialized care and no possibility of being transferred to a

proper healthcare unit can be provided KMC as the sole

modality of care. In such cases, KMC including skin-to-skin

contact, breastfeeding and adequate follow-up represent the

best available means of survival of non-sick premature infants. 2. Specialized care but limited resources

KMC represents an effective alternative which allows better

utilization of available resources in these settings3. Specialized care and adequate resources

KMC is used as an adjunct to technology based care to

establish healthy bonding between mother and newborn and

to increase the breastfeeding rates. The intermittent kangaroo

position in hospital is the most widely used component in such

a setting.

KMC in different settings

KMC may be used in three different scenarios

618

AIIMS Protocols in Neonatology

6-8Requirements for KMC implementation KMC is feasible everywhere, because it is not based on equipment, and it presents advantages for the organization of health services provided the following requirements are met:1. Appropriate health facility

a. The health facility should allow entry of the parents to the neonatal unit at all times

b. A room near to or at the neonatal unit, furnished with comfortable seats for mothers is needed for KMC practice and for education of mothers and families

c. Reclining chairs in the nursery and postnatal wards, and beds with adjustable back rest should be arranged

d. Mother can also provide KMC sitting on an ordinary chair or in a semi-reclining posture on a bed with the help of pillows

2. Appropriate supporting staff and professionalsa. Presence of a nurse available full time and trained in

assisting mothers in KMC is a mustb. Staff should receive adequate training on KMC.

Additional training is needed for expression and storage of breast milk, using alternate methods of feeding, and daily monitoring of growth of LBW neonates. The training may best be done by exposing them to units practicing KMC

c. Educational material such as information sheets, posters, and video films on KMC in local language should be available to the mothers, families and the community

3. Good quality follow-upa. Early discharge in kangaroo position should be

attempted only if adequate and appropriate follow up can be ensured

4. Institutional, social and community supporta. The requirement for a successful KMC program can be

summarized in three words: communication, sensitiveness and education

b. Apart from supporting the mother, family members should also be encouraged to provide KMC when the mother wishes to take rest

c. Mother would need her family’s cooperation to deal with

619

Kangaroo Mother Care

her conventional responsibilities of household chores till the infant requires KMC

d. Community awareness about the benefits should be created. This is particularly important when there are social, economic or family constraints

1. NeonatesAll stable LBW neonates are eligible for KMC. However, sick

and very small neonates (<1200 g) needing special care need to

be cared under radiant warmer initially. KMC need to started

once the neonate is hemodynamically stable. Short KMC

sessions can be initiated during recovery. KMC can be

provided while the neonate is being fed via orogastric tube or

on oxygen therapy. Figure 50.1 shows the timing of KMC

initiation for different birth weight categories.

Figure 54.1: Timing of KMC initiation fordifferent birth weight categories

6-8Criteria for eligibility of KMC

620

Birth weight

>1800 g<1200 g 1200 to 1800 g

Most suffer from serious morbidities

• Many suffer from serious morbidities

• Transfer to a specialized centre, if possible

• Best transported in STS with mother / family member

Generally stable at birth

May take days to weeks before KMC can

be initiated

May take days beforeKMC can be initiated

KMC can be initiatedimmediately after birth

AIIMS Protocols in Neonatology

2. Mother/relativesAll mothers can provide KMC, irrespective of age, parity,

6education, culture and religion.The following points must be taken into consideration when counselling on KMC:1. Willingness: The mother must be willing to provide KMC.

Healthcare providers should counsel and motivate her. Once the mother realizes the benefits of KMC, she will learn and undertake KMC

2. General health and nutrition: The mother should be free from serious illness to be able to provide KMC. She should receive adequate diet and supplements recommended by her physician

3. Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes, hand washing, short and clean finger nails

1. Counselinga. When the neonate is ready for KMC, arrange a time that is

convenient to the mother and her babyb. Demonstrate to her the KMC procedure in a caring and

gentle manner and with patience. Answer her queries and allay her anxieties

c. Encourage her to bring her mother/mother in law, husband or any other member of the family. This helps in building positive attitude of the family and ensuring family support to the mother which is particularly crucial

8 for post-discharge home-based KMCd. It is helpful that the mother starting KMC interacts with

someone already practicing KMC2. Mother’s clothing

a. Mother can wear any front-open dresses as per local culture. This may include sari, a blouse, front open gown, a suit, or a simple shirt (Figure 50.2)

b. KMC can be done with special apparel (such as KEM bag or AIIMS KMC jacket) designed to suit the needs of mothers

c. Any other suitable apparel that can retain the neonate for extended period of time can be used

Initiation of KMC

621

Kangaroo Mother Care

3. Baby’s clothingBaby is dressed with cap, socks, nappy, and a front-open sleeveless shirt

1. Kangaroo positioning (Figure 54.3)

a. The neonate should be placed between the mother’s breasts in

an upright position

b. The head should be turned to one side and kept in a slightly

extended position. This position keeps the airway open and

allows eye to eye contact between the mother and her baby

c. The hips should be flexed and abducted in a “frog” position;

the arms should also be flexed. Baby’s abdomen should be at

the level of the mother’s epigastrium. Mother’s breathing

stimulates the baby, thus reducing the occurrence of apnea

d. Support the baby’s bottom with a sling/binder

Figure 54.2: Mother (A) and father (B) practicing KMC in front open gown and shawl. AIIMS KMC jacket (C) and mother performing

KMC using AIIMS KMC jacket (D)

6-8KMC procedure

622

A B

C D

AIIMS Protocols in Neonatology

Figure 54.3: Positioning in KMC

2. Monitoringa. Neonates receiving KMC should be monitored carefully.b. Nursing staff should make sure that neonate’s neck

position is neither too flexed nor too extended, airway is clear, breathing is regular, color is pink and the neonate is maintaining temperature

c. Mother should be involved in observing the neonate during KMC so that she herself can continue monitoring at home

3. Feedinga. The mother should be explained how to breastfeed while

the neonate is in KMC position. b. Holding the neonate near the breast stimulates milk

5,6productionc. She may express milk while the neonate is still in KMC

position. The neonate could be fed with paladai, spoon or tube, depending on his/her clinical condition

4. Durationa. Skin-to-skin contact should start gradually in the nursery,

with a smooth transition from conventional care to continuous KMC

b. Sessions that last less than one hour should be avoided because frequent handling may be stressful for the neonate

c. The length of skin-to-skin contacts should be gradually

increased up to 24 hours a day, interrupted only for

changing diapers

623

Baby betweenmother’s breasts

Support baby’sbottom

Head turnedto one side

Frog-legposition

Kangaroo Mother Care

d. When the neonate does not require intensive care, she

should be transferred to the post-natal ward where KMC

should be continued

The mother can sleep with her baby in kangaroo position in

reclined or semi recumbent position about 30 degrees from

horizontal (Figure 54.4). This can be done with an adjustable bed or

with pillows on an ordinary bed. A comfortable chair with an

adjustable back may be used for resting during the day (Figure

54.4).

Discharge criteriaThe standard policy of the unit for discharge from the hospital should be followed. Generally the following criteria are used at

7most centres: • Baby’s general health is good • Gaining weight (at least 15-20 g/kg/day for three consecutive

days)• Maintaining body temperature satisfactorily for at least three

consecutive days in room temperature.• Feeding well and receiving exclusively or predominantly

breast milk.• The mother and family members are confident to take care of

the baby

7Can the mother continue KMC during sleep and resting?

624

Figure 54.4: Mother practicing KMC in recliningposture (A) and KMC chair (B)

A B

AIIMS Protocols in Neonatology

When to discontinue KMC?

Post-discharge follow-up

Barriers and enablers of kangaroo mother care

KMC is continued for as long as possible at the health facility & then at home. Often this is desirable until the gestation reaches term or the weight is around 2500 g. The time when the infant starts wriggling to show that she is uncomfortable, pulls her limbs out, cries and fusses every time the mother tries to put her back skin-to- skin is the time to wean her from KMC. Even after weaning, mothers can provide skin-to-skin contact occasionally after giving the baby a bath or during cold nights.

Close follow up is a fundamental pre-requisite of KMC. The infant is followed once or twice a week till 37-40 weeks of gestation or till he/she reaches 2.5 to 3 kg of weight. Thereafter, a follow up once in 2-4 weeks may be enough till 3 months of post-conception age. Later the baby should be seen at an interval of 1-2 months during first year of life. The baby should gain adequate weight (15-20 gm/kg/day up to 40 weeks of post-conception age and 10 gm/kg/ day subsequently). More frequent visits should be made if the infant is not growing well or his condition demands.

To support kangaroo mother care implementation, one needs context-specific materials, including guidelines, sociocultural norms and behaviour change materials. In addition, systematic training curriculums for health care professionals and mothers, and bed side job aids are needed.

The stress associated with birth of a preterm neonate is compounded by lack of knowledge about KMC among parents, families and health-care workers. This eventually leads to hindrance in ‘buy-in’ and support from parents and families for practicing KMC. These barriers can be overcome by clear articulation of the benefits for mothers, newborns, caregivers and health-care workers. Engagement of fathers in childcare can help overcome these barriers. In addition, team work and collaboration amongst health care providers can work wonders.

Kangaroo mother care should be practiced systematically and consistently with motivated trained staff, targeted education of

625

Kangaroo Mother Care

staff and parents, clear eligibility criteria, and improved referral practices and creation of community group in kangaroo mother

9,10care participants through support groups.

1. Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiological response to skin to skin contact in hospitalized premature infants. J Perinatol.1991; 11: 19-24

2. Whitelaw A, Heisterkamp G, Sleath K, Acolet D, Richards M. Skin to skin contact for very low birthweight infants and their mothers. Arch Dis Child 1988; 63(11):1377-81.

3. Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother method: randomized controlled trial of an alternative method of care for stabilized low-birthweight infants. Maternidad Isidro Ayora Study Team. Lancet 1994; 344(8925):782-5.

4. Charpak N, Ruiz-Pelaez JG, Charpak Y. Rey-Martinez Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study. Pediatrics 1994; 94(6 Pt 1):804-10.

5. Conde-Agudelo A, Belizán JM, Diaz-Rossello J, Jose L. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2016August 16; (3):CD002771.

6. Udani RH, Nanavati RN. Training manual on Kangaroo mother care. Published by the Department of neonatology. KEM Hospital and Seth GS medical college Mumbai. September 2004.

7. Website of KMC India Network. Guidelines for parents and health providers are available online at www.kmcindia.org17.

8. World Health Organization. Kangaroo mother care: a practical guide. Department of Reproductive Health and Research, WHO, Geneva.2003.

9. Johnson AN. Factors influencing implementation of kangaroo holding in a Special Care Nursery.MCN Am J Matern Child Nurs. 2007. Jan-Feb;32(1):25–9.

10. Eichel P. Kangaroo care: Expanding our practice to critically III neonates. Newborn Infant Nurs Rev. 2001;1(4):224–8.

References

626

AIIMS Protocols in Neonatology